Recently, with a similar situation, a 88 yo female also diagnosedgastric ca. with a "bleeding" complication was scheduled for presumably "palliative" gastrectomy. Intraoperative finding showed a good size lesion (grossly 4-5 cm) on the anterior wall, too close toGE junction to get a 6 cm margin. (+) peritoneal seeding.What do you do, assuming she is an OK surgical candidate 88 yo? ? It's wrong to operate, to begin with? ? Total gastrectomy? One, including my attd, feared M&M ? Big wedge excision, which we did, and left behind a very ugly,and funny bottle-shaped deformity stomach remnant.

Marcel wrote:About the operation in this case let me be a devil's advocate.Ofcourse total gastrectomy with a distal pancreatectomy are a "fun"procedure and a "piece of cake" for us big surgeons. But it is associatedwith a well documented high M &M. Is the latter justified? Does ittranslates to a better survival rate and better quality of life? Thislady was not really "bleeding", David- a little iron over 6 months is nota "great deal" . You know that gastric ca patients very rarelyexanguinate. You mentioned "palliation" but what are you really palliatinghere?

You are experts in ca stomach- are you convinced thatradical surgery will really prolong this patient's life and it's quality-ofcourse if she survives with God's helps- and without antibiotics- the"second hit".

A. have done a perfect job for this lady, he gave her a chance of 25%five years survival, compared to 0% five years survival if a lesser operationor palliative procedure was performed. Any M&M will be acceptable in thebackground of 0% five years survival. If complete resection (R0) is achieved,extended resection for locally advanced gastric carcinoma provides survivaltime, which is comparable, stage for stage, with survival rates observed afterR0 resection for cancer limited to the stomach.

Resident wrote:Recently, with a similar situation, a 88 yo female also diagnosedgastric ca. with a "bleeding" complication was scheduled for presumably "palliative" gastrectomy. Intraoperative finding showed a good size lesion (grossly 4-5 cm) on the anterior wall, too close toGE junction to get a 6 cm margin. (+) peritoneal seeding.What do you do, assuming she is an OK surgical candidate 88 yo? ? It's wrong to operate, to begin with? ? Total gastrectomy? One, including my attd, feared M&M ? Big wedge excision, which we did, and left behind a very ugly,and funny bottle-shaped deformity stomach remnant.

Peritoneal dissemination in cancer stomach is a contraindication for any surgical intervention, you can diagnose it preoperatively by a rectal examination, or by laparoscopic inspection beforelaparotomy. The worst thing to do in cancer stomach is to cut through malignant tissue, or to leave malignant tissue behind, local recurrence is very quick and is a terribly devastating event.Unfortunately you have done the worst option to your patient.

To answer your questions,I must say that we consider that the presence ofperitoneal seeding,P1 or P2, is a contrindication to any kind of surgicalprocedure...And so it is...The outcome of patients in whom any resectionwith anastomosis procedure is performed, is bad,with all sort ofcomplications and,at the the end,you have waisted lots of time,provoked toomuch suffering and no significant survival is obtained...

Perhaps in front of an 88 y.o. female,with a well localized lesion of about5 cms in diameter,with bleeding problems,in spite of peritoneal seeding,youfeel tempted to practice what you did : a big wedge excission and,even ifthat has no oncological base,it might be enough for such a patient...Hopeshe did well and no complications appeared.

Marcel wrote:About the operation in this case let me be a devil's advocate.Ofcourse total gastrectomy with a distal pancreatectomy are a "fun"procedure and a "piece of cake" for us big surgeons. But it is associatedwith a well documented high M &M. Is the latter justified? Does ittranslates to a better survival rate and better quality of life?

In the CURATIVE (T1-3, N0-1/2, M0) situation, which this is not, atotal gastrectomy, no splenectomy, should always be done for proximaltumours. In the PALLIATIVE situation for proximal tumours, I have toagree with you: most are irresectable, and iron and the oddtransfusion palliates well. But, on occasion, there is a littlesubset of tumour which is locally invasive, and apparently nonmetastasizing, which comes out easily and safely, with prolongedpalliation. Its a case of intra-operative judgement and strategy, and "if I dothis, will she be home & eating in 10 days?" The patientdescribed is not one of those, I dont think,and your conservatism isprobabl;y good judgement.

A total gastrectomy is not "radical" surgery, it is merely theremoval of a handful more stomach; a lymphadenectomy orremoval of adjacent organs en bloc is. But here we descend into thesemantics and connotations of that word "radical".

Wired wrote:A total gastrectomy is not "radical" surgery, it is merely theremoval of a handful more stomach; a lymphadenectomy orremoval of adjacent organs en bloc is. But here we descend into thesemantics and connotations of that word "radical".

In your multiple prior publications on this topic you claimed that being"radical" in term of lymphnode dissection is not beneficial. Is resectionof adjacent organs beneficial? What do you think about that Am J Surgpaper-quoted here by my honorable friend Mohammed to support adjacent organresections in T4 lesions?

Radical lymphadenectomy for gastric carcinoma has not withstoodthe steely scrutiny of randomised trials.

There have been no trials examining whether adjacent organ removal isof value [morbidity, mortality, survival, QOL] with gastriccarcinoma. Instead, there have been many publications comparingpatients who had [ie were able to have] adjacent organ removal, tothose who did not [ie were not able to have], both in the T4category. I use these articles for teaching: "Now today we aregoing to talk about SELECTION BIAS in Surgery...". The easy ones getthe op, the difficult ones dont; easy ones do well - ergo it is theop.

Nonetheless, there is a tiny subset of patients (not defined byhistological type or grade) that appear to be locally invasive, andnot generally disseminating. We have all seen this in the breast,too. Tail of pancreas, bit of colon, bit of liver, out with thegastrectomy. Very unusual, I agree, but there are these cases.

You have just nudged me into going to our database to punch inT4NXM0; SX; laparotomy, no SX.

Why do you need an RCT for this? It is clear that if you do nothing forT4 lesions there will be no 5 year survivors. If you remove, you will getsome (up to 25% in some series, higher if nodes are negative and there aresome T4N0 patients). There is no deed to do an RCT, if the results ofone alternative are 100% certain.

Of course the patients are selected. The easy ones are done. Those withlarge palpable lymphnodes are excluded. The best evidence for this is thatthe rate if T4N0 lesions in these series is around 30%, highly unlikely tobe the figure in the T4 population at large.

The selection only means that the conclusions apply only to similarlyselected patients, ie relatively healthy patients where resection isdeemed technically easy and who have no bulky celiac nodes or positiveparaaortic.

Now even in the selected patients the operative mortality for T4's is10-15%.

So the question becomes the following (for the selected case): does oneaccept a 15% immediate mortality and say 25% chance of 5 year survival,vs. no immediate mortality and survival in the range of 3 months to saytwo years.

I believe the choice between the two belongs to the patient, not thesurgeon. It is a matter of values, not technical expertise.

I ask the patients before the operation about their preferences. If theyare risk-averse, as many of them are, I would not do a radical operation.But if they accept the risk I would, if they fit the selection criteria.I also document the discussion in the chart.

Your observations are in my opinion absolutely correct. Conservatism diesslowly especially in certain enviroments.Er deduces that I choseHartmann's procedure to protect myself rather than look after thepatients interest. This is not correct . The reason i chose Hartmann , isthat colonic Traumatic lesions are rare in our enviroment and nobody hadventured for primary anastomosis( No local track record) .However , Ithink that after all these discussions one can easily face any oppositionarmed by a consensus of opinions( Viva free speech and exchange ofideas).

I'm not so sure about this. I try to do what is right for the patient and Ido try very hard to keep up to date: for-surgeons.com, other e-mail groups, meetings,over 100 CME credits per year.

However, I still run into a lot of criticism from the local surgeons, whodon't even look at my Medline articles, textbook articles, for-surgeons.com and othere-mail group notes. They consider them irrelevant to the discussion. Lasttime, I finally had to tell them I was bringing my lawyer to any furtherdiscussions. For some reason, this scared them. I think it also made themsee that I am a serious person and they should take me seriously. One localsurgeon told me privately and in front of the entire Medical Executivecommittee that he was going to run me out of town. I'm still here close to 2years later.